A patient with newly diagnosed invasive ductal carcinoma, positive for estrogen and progesterone receptors and negative for HER2, is being evaluated for treatment options. Considering her BRCA1 mutation, family history, and potential metastatic sites, which of the following nursing interventions is most critical to prioritize in the care plan?

D) Monitor liver function tests closely and assess for signs of liver dysfunction due to suspected metastatic involvement.

A) Educate the patient on the importance of adhering to antihypertensive and diabetic medications to reduce treatment complications.

B) Prepare the patient and family for the possibility of mastectomy and discuss postoperative expectations.

C) Coordinate with the multidisciplinary team to initiate genetic counseling and consider prophylactic measures for the contralateral breast.

D) Monitor liver function tests closely and assess for signs of liver dysfunction due to suspected metastatic involvement.

A 52-year-old female with newly diagnosed invasive ductal carcinoma, positive for estrogen and progesterone receptors and negative for HER2, with confirmed BRCA1 mutations, is preparing for a multidisciplinary team meeting to discuss treatment options. Given her current diagnosis and comorbidities of hypertension and diabetes, what should the nurse prioritize in preparing the patient for potential systemic chemotherapy and hormone therapy?

A) Educating the patient on the importance of routine blood glucose monitoring and blood pressure management during treatment.

B) Advising the patient to increase physical activity to combat fatigue associated with chemotherapy.

C) Encouraging the patient to start a high-calcium diet to prevent osteoporosis related to hormone therapy.

D) Instructing the patient to avoid all fatty foods to reduce liver enzyme levels before starting treatment.

A patient undergoing systemic chemotherapy and endocrine therapy for breast cancer presents with persistent fatigue, mild jaundice, and diffuse upper abdominal discomfort. Laboratory results indicate elevated liver enzymes and bilirubin levels. What is the priority nursing intervention to address this complication?

C) Collaborate with the healthcare team to adjust the chemotherapy regimen.

A) Administer prescribed antiemetics to manage nausea and vomiting.

B) Encourage the patient to increase fluid intake to promote kidney function.

C) Collaborate with the healthcare team to adjust the chemotherapy regimen.

D) Educate the patient on the importance of a low-fat diet to reduce liver strain.

A patient undergoing chemotherapy and endocrine therapy for hormone receptor-positive breast cancer presents with fatigue, mild jaundice, and upper abdominal discomfort. Laboratory tests reveal elevated liver enzymes and bilirubin levels. Which nursing intervention is the priority to address the patient's current condition?

C) Monitor liver function tests closely and report significant changes to the oncology team.

A) Encourage the patient to increase physical activity to combat fatigue.

B) Administer prescribed antiemetic medication to prevent nausea.

C) Monitor liver function tests closely and report significant changes to the oncology team.

D) Educate the patient about dietary modifications to manage jaundice.

A patient with metastatic breast cancer and liver involvement is experiencing worsening fatigue, anorexia, nausea, and hypotension. Which nursing intervention is most appropriate to address the patient's current symptoms and improve her overall well-being?

B) Administer prescribed intravenous fluids and antiemetic medications.

A) Encourage the patient to increase oral fluid intake.

B) Administer prescribed intravenous fluids and antiemetic medications.

C) Teach the patient relaxation techniques to manage fatigue.

D) Provide the patient with a high-calorie, high-protein diet.

A patient with metastatic breast cancer and liver involvement is experiencing worsening fatigue, anorexia, nausea, and mild tachycardia. She has been switched to a less hepatotoxic chemotherapy regimen. Which nursing intervention is most appropriate to address the patient's current symptoms and support her recovery?

A) Encourage frequent small meals high in protein and calories to improve nutritional intake.

B) Increase the patient's activity level to improve cardiovascular function and reduce fatigue.

C) Administer a diuretic to manage potential fluid overload and reduce blood pressure.

D) Limit fluid intake to prevent potential fluid retention and exacerbate hypotension.

A patient with metastatic liver disease is experiencing worsening jaundice and pruritus, and recent labs indicate elevated bilirubin and liver enzymes. The oncology team is considering the introduction of ursodeoxycholic acid. What is the primary purpose of ursodeoxycholic acid in this patient's treatment plan?

B) To improve bile flow and reduce cholestatic symptoms.

A) To reduce liver enzyme levels by enhancing liver regeneration.

B) To improve bile flow and reduce cholestatic symptoms.

C) To increase the patient's nutritional intake by improving appetite.

D) To prevent further metastatic spread to other organs.

A patient with metastatic liver lesions presents with worsening jaundice and pruritus, accompanied by elevated bilirubin and liver enzymes. The healthcare team is considering the use of ursodeoxycholic acid to alleviate symptoms. Which nursing intervention is most appropriate to prioritize in the care plan to address the patient's current condition?

B) Monitor the patient's skin integrity and provide regular skin care to manage pruritus.

A) Educate the patient and family about the importance of a low-fat diet to reduce liver workload.

B) Monitor the patient's skin integrity and provide regular skin care to manage pruritus.

C) Assess the patient’s neurological status regularly for signs of hepatic encephalopathy.

D) Prepare the patient for potential imaging studies to evaluate biliary obstruction.

A patient with metastatic liver disease is experiencing persistent jaundice and pruritus despite initial treatment with ursodeoxycholic acid and corticosteroids. The healthcare team is considering interventional procedures to relieve biliary obstruction. What is the most appropriate nursing action to prioritize before the procedure?

B) Ensure the patient is NPO (nothing by mouth) as per the pre-procedure protocol.

A) Educate the patient on the potential risks and benefits of the procedure.

B) Ensure the patient is NPO (nothing by mouth) as per the pre-procedure protocol.

C) Administer prescribed anti-pruritic medication to improve comfort.

D) Obtain baseline vital signs to assess the patient's current status.

A patient with metastatic hepatic lesions and biliary obstruction is experiencing persistent jaundice and pruritus despite treatment with ursodeoxycholic acid and corticosteroids. What is the most appropriate nursing intervention to prioritize at this time to address the patient's symptoms and improve quality of life?

B) Collaborate with the healthcare team to evaluate the need for interventional procedures like percutaneous biliary drainage.

A) Encourage the patient to adhere to a low-fat, high-protein diet to reduce liver strain.

B) Collaborate with the healthcare team to evaluate the need for interventional procedures like percutaneous biliary drainage.

C) Increase the corticosteroid dosage to reduce inflammation and bilirubin levels.

D) Educate the patient on skin care techniques to manage pruritus more effectively.

Breast cancer - Nursing Case Study

Pathophysiology

• Primary mechanism: Genetic mutations in BRCA1 and BRCA2 genes lead to defective DNA repair mechanisms, increasing the risk of malignant transformation in breast cells. This results in uncontrolled cell growth and tumor formation.

• Secondary mechanism: Hormonal influence, particularly elevated levels of estrogen, can promote the proliferation of breast cells. Estrogen receptors on breast tissue bind to the hormone, driving cell division and potentially leading to cancer if cell regulation is compromised.

• Key complication: Metastasis occurs when cancer cells invade nearby tissues or spread through the lymphatic system or bloodstream, leading to the establishment of secondary tumors in distant organs, complicating treatment and reducing survival rates.

Patient Profile

Demographics:

52-year-old female, school teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes, Family history of breast cancer

• Current medications: Metformin, Lisinopril, Tamoxifen

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Breast lump with recent increase in size

• Key symptoms: Fatigue, night sweats, localized breast pain, lymph node swelling in the armpit

• Vital signs: Blood pressure 150/95 mmHg, heart rate 95 bpm, respiratory rate 20 breaths per minute, temperature 100.1°F

Section 1

New Diagnostic Results:

Following the initial presentation, the patient underwent a series of diagnostic tests to evaluate the extent and nature of the breast cancer. A mammogram confirmed the presence of a suspicious mass in the upper outer quadrant of the right breast, measuring approximately 3.5 cm in diameter. An ultrasound-guided core needle biopsy was performed, revealing invasive ductal carcinoma with positive estrogen and progesterone receptors, but negative HER2 status, indicating hormone receptor-positive breast cancer. Further genetic testing confirmed the presence of BRCA1 mutations, aligning with her family history and increasing her risk for more aggressive cancer behavior.

To assess the potential for metastasis, a PET scan was conducted and showed increased metabolic activity in the right axillary lymph nodes, suggesting nodal involvement. Additionally, there was a concerning uptake noted in the contralateral breast and a small lesion in the liver, raising suspicion for possible metastatic spread. Laboratory tests revealed a slightly elevated liver enzyme profile, with AST and ALT levels at 68 U/L and 75 U/L, respectively, further supporting the need for a comprehensive metastatic workup. Tumor markers, including CA 15-3, were elevated, contributing to the suspicion of systemic involvement.

These findings necessitate a multidisciplinary team discussion to determine the best course of action, balancing systemic chemotherapy with targeted hormone therapy, and considering surgical options for tumor resection. The patient's current physiological state, including her hypertension and diabetes, must also be carefully managed to optimize treatment outcomes and minimize the risk of treatment-related complications. This pivotal point in her care requires careful coordination to address the potential spread of disease while mitigating the impact on her overall health and quality of life.

Section 2

New Complications:

As the multidisciplinary team began to implement the treatment plan, the patient was started on a regimen of systemic chemotherapy combined with endocrine therapy to address the hormone receptor-positive nature of her breast cancer. However, within a few weeks of initiating treatment, the patient presented to the oncology clinic with new symptoms, including persistent fatigue, mild jaundice, and diffuse upper abdominal discomfort. Clinical assessment revealed scleral icterus and hepatomegaly upon palpation. The patient's vital signs indicated a mild tachycardia at 102 beats per minute, blood pressure of 138/85 mmHg, respiratory rate of 20 breaths per minute, and oxygen saturation of 95% on room air.

Laboratory evaluation showed a further increase in liver enzymes, with AST rising to 95 U/L and ALT to 102 U/L. Total bilirubin was elevated at 2.8 mg/dL, and direct bilirubin at 1.5 mg/dL, indicating hepatic dysfunction. These findings, coupled with the patient's clinical presentation, suggested a possible progression of liver metastasis or chemotherapy-induced hepatotoxicity. The oncology team was concerned about the potential hepatic involvement and the impact of current treatments on liver function.

Given these developments, the treatment plan required urgent reassessment. The team discussed the need for a liver MRI to better characterize the lesions and evaluate the extent of hepatic involvement. Moreover, they considered modifying the chemotherapy regimen to reduce liver strain, balancing the need for effective cancer control with the patient's current hepatic status. This new complication emphasized the importance of continuous monitoring and assessment to mitigate risks and adjust treatment strategies as the patient's condition evolved. As such, adjustments in supportive care, including liver function management and symptom control, were prioritized to maintain the patient's quality of life during this challenging phase of her treatment journey.

Section 3

As the oncology team proceeded with the planned liver MRI, the imaging results revealed multiple hepatic lesions consistent with metastatic disease, confirming the progression of liver metastasis. Given these findings, the team recognized the urgent need to modify the current chemotherapy regimen to prevent further liver damage while still aiming to control cancer progression. A decision was made to transition the patient to a less hepatotoxic chemotherapy agent combined with a different endocrine therapy, which was anticipated to be more suitable for her current hepatic status.

During this period, the patient's clinical status experienced further change. She began to exhibit symptoms of worsening fatigue and anorexia, alongside episodes of nausea and vomiting, which impacted her nutritional intake and overall well-being. Vital signs revealed a persistent mild tachycardia at 105 beats per minute and a new finding of hypotension with a blood pressure of 95/60 mmHg, indicating possible dehydration or evolving hemodynamic instability. The multidisciplinary team quickly initiated supportive measures, including intravenous fluids and antiemetic therapy, to manage these symptoms and ensure adequate hydration and nutritional support.

In response to these interventions, the patient's condition showed a gradual improvement. Her fatigue and nausea began to decrease, allowing for better oral intake and stabilization of her hemodynamic status. However, the team remained vigilant, aware of the potential for further complications due to the ongoing metastatic process. Regular monitoring of liver function tests and clinical symptoms was prioritized to promptly identify any new issues, ensuring that the treatment plan could be adjusted as needed to maintain her quality of life and manage her breast cancer effectively.

Section 4

As the team continued to monitor the patient, new complications emerged. Despite the initial improvement following supportive interventions, the patient began experiencing worsening jaundice and pruritus. This prompted an urgent reassessment of her liver function. Laboratory results showed a marked increase in bilirubin levels, now at 4.5 mg/dL, along with elevated liver enzymes, indicating further hepatic deterioration. The multidisciplinary team interpreted these findings as signs of worsening liver function secondary to the metastatic burden. Given the new onset of jaundice and pruritus, there was a growing concern for cholestasis, possibly due to obstruction from hepatic lesions.

Recognizing the need to address these symptoms and prevent further complications, the oncology team discussed the possibility of additional imaging to evaluate the degree of biliary obstruction. Concurrently, they considered the introduction of ursodeoxycholic acid to help alleviate the cholestatic symptoms and improve bile flow. The patient's nutritional status continued to be a priority, and the dietitian was consulted to recommend a low-fat diet that could potentially reduce the metabolic load on the liver and improve her overall comfort.

The team remained focused on integrating these new findings into the patient's treatment plan, emphasizing the importance of balancing cancer control with the management of hepatic symptoms. This required ongoing communication and coordination among the oncology, hepatology, and supportive care teams. The patient's family was also engaged in discussions about her care goals, ensuring that her treatment pathway aligned with her values and preferences. As the team navigated these complexities, they prepared for the possibility of further therapeutic adjustments, aware that maintaining the patient's quality of life was of utmost importance in the context of her advanced disease.

Section 5

As the team proceeded with additional imaging studies, a contrast-enhanced MRI of the abdomen was performed to evaluate the extent of biliary obstruction. The results revealed multiple hepatic lesions consistent with metastatic disease, with significant compression of the intrahepatic bile ducts. This confirmed the suspicion of biliary obstruction contributing to the patient's cholestatic symptoms. Concurrently, the patient's vital signs remained relatively stable, with a blood pressure of 110/70 mmHg, heart rate of 88 bpm, respiratory rate of 18 breaths per minute, and an oxygen saturation of 96% on room air. However, she reported increased fatigue and a noticeable decline in appetite, likely related to her hepatic dysfunction and systemic disease progression.

The oncology team, in collaboration with hepatology, initiated treatment with ursodeoxycholic acid to potentially improve bile flow and alleviate pruritus. Additionally, the patient was started on a low-dose corticosteroid regimen to address inflammation and provide symptomatic relief. The dietitian recommended a low-fat, high-protein diet to support her nutritional needs while minimizing the metabolic demand on her liver. Despite these interventions, the patient's bilirubin levels continued to rise, now reaching 5.8 mg/dL, indicating ongoing hepatic compromise.

In light of the patient's persistent jaundice and pruritus, and the limited response to initial interventions, the team discussed the potential benefit of interventional procedures, such as percutaneous biliary drainage or stenting, to relieve bile duct obstruction. They also considered adjusting the chemotherapy regimen to better control the metastatic disease burden while minimizing hepatic toxicity. Throughout these discussions, the team maintained open communication with the patient and her family, ensuring that her preferences and quality of life considerations remained central to the decision-making process. As they navigated these challenges, the team prepared to reassess the patient's condition and treatment response, ready to pivot strategies to optimize her care and comfort.